'When you hear hoofbeats, think of horses not zebras' - the old adage is well-known to GPs but what should you do when faced with a zebra, not a horse? Consultant cardiologist Professor Robert Tulloh and GP Dr Louise Tulloh kick off our new series with their advice on how to catch Kawasaki disease in general practice.

Let’s celebrate 69 years of the NHS by pledging to fight for it

Today the NHS celebrates its 69th anniversary, but it now faces one of the most difficult periods in its history. This Government’s policies and privatisation agenda mean the NHS and general practice in particular will be gone for ever. The way this NHS is being managed by Jeremy Hunt and the government is a stunning example of how not to do things. The roadmap of its policies is leading to the complete destruction of the time tested model of traditional general practice in England.

I believe it will be a completely different primary care system in next few years – one which will be much worse in terms of access, equity, health outcomes and cost. What we are left with is confusion and uncertainty. In so many areas the NHS is at a crossroads. It now faces a recipe for indecision which could harm the service and those it serves. Cuts in the name of ‘efficiency savings’ have eaten away at the NHS to the point where it is down to its bare bones. We have got to the point where the efforts of the NHS family to prop up the system are no longer enough to keep the system afloat. The government is deliberately setting up the NHS to fail, that’s clear. The whole agenda of the Jeremy Hunt & Co is to wash its hands of the NHS. The biggest evidence is that they are starving the NHS of the funding it needs so that eventually they will say that it’s unaffordable.

The general practice model of the past 69 years could see revolutionary changes. We might begin to see GPs working as part of a broader non-acute sector, in larger teams, in different settings, and for new employers, under new ‘Accountable Care Organisations’ and Sustainability and Transformation Plans. A new tier of physician associates is planned, along with more nurses and pharmacists. These skilled non-medical professionals could be allowed to take on the bulk of work traditionally only associated with GPs. All of this would be unrecognisable to a GP from 1948. Primary care is undergoing some significant and worrying changes that demonstrate a lack of value placed on the quality of general practice. The Government appears to be determined to move from traditional GP partnerships to ones where the private sector would play a much greater part in the future structure and running of general practice, with a salaried model.

The current changes being imposed across NHS primary care are leading to the meltdown and eventual destruction of general practice in this country. Private sector providers want to de-professionalise and down-skill the practice of medicine in this country, so as to make staff more interchangeable, easier to fire, more biddable, and above all, cheaper.

The failure to acknowledge the crisis facing GP services – an under-resourced, over-stretched shell of their former selves, struggling to keep pace with patient demand despite the efforts of their staff – could finish off general practice, the ‘jewel in the crown of the NHS’, for good.

General practice is the bedrock of many NHS services and the gatekeeper to the rest. The BMA and RCGP need to unite and confront the realities facing practices and make plans now to fight this politically motivated assault on primary care and reverse the crisis facing general practice – or we can bury our heads in the sand and watch this key part of the health service slide into terminal decline.If general practice fails, the whole NHS fails.

On the NHS’s 69th birthday we need to re-commit to its founding principles and general practice’s importance to healthcare provision and the survival of the NHS.

HAPPY 69th ANNIVERSARY NHS, WE WILL KEEP FIGHTING TO SAVE IT !

Dr Kailash Chand is a retired GP from Tameside and is Honorary Vice-President of the BMA

Rate this article
(4.33 average user rating)

Readers' comments (7)

Why is the NHS, the system of funding and organising healthcare in the UK, special?
I suggest the doctors, nurses, receptionists, porters, midwives etc etc are the main asset, and they would be just as professional in a system modeled after the best performing European non NHS systems in 2017.

Fine words Kailash (Honorary Vice President of the BMA). You describe the Primary Care train wreck so eloquently. What is the BMA actually going to do? Carry on sitting on its hands I'd wager.... useless.... You must be so proud. You don't know what you've got until it's gone!

IMG_0277Mary McCarthy is a GP in Shrewsbury., She is on the GPC and is interested in comparative health systems. She is the BMA rep to UEMO.

Oct 2015

UEMO (Union Européenne des Médecins Omnipraticiens) represents GPs in 26 European member states. It develops policy and projects to support family medicine and to share best practice. It also provides an opportunity to look at other health systems and to learn from them, studying alternative ways of working and investigating ideas that may help with UK general practice.

Earlier this year, a questionnaire was circulated by the UK delegation that asked about workload pressures in the differing EU member states. A total of 25 states replied (Malta gave two answers for their public and their private health care systems) and although the data set is incomplete, it still makes interesting reading and an overview of the findings is presented here.

Different models, different responsibilities

Not all countries have registered lists of patients. Often it divides, as it does in the Irish Republic, into those that are covered by a means-tested state-led system who have to be registered to take advantage of the financial benefits, and those who pay privately for health care, either through an insurance-based system or through their own pocket.

Sometimes, as in France, there is no requirement to register but because insurance companies offer incentives, 90% of patients do.

In Europe, Family Doctors may act as gate-keepers, as they do in the UK, or as signposts where they just act as a conduit to secondary care. The second course means that they do not deal with chronic disease management so do not have the pressures that the increasing shift to general practice of disease management that used to be dealt with in hospital clinics. In many EU states, children are seen by paediatricians not by GPs and gynaecological problems are referred for examination and investigation to gynaecologists.

Elderly people who are resident in nursing homes may be under the care of Community Physicians or, as in Holland, Nursing Home Doctors. Mental illness may be referred directly to secondary care.

Workload and practice

List sizes vary from 600 per GP in Belgium to 3,500 per GP in Turkey and consultation rates per GP vary from 10 a day to 50 a day. This figure is confused by the fact that some replies counted telephone consultations as well where other nations just rated face-to-face consultations.

Group practices are gradually becoming the norm throughout Europe, though Belgium still has only 3% of practices with more than one doctor. In Italy roughly 50% of practices are group practices and in the Netherlands about 75%. The UK is still far ahead with more than 90% of practices being group practices. E also have larger groups of doctors. In much of Europe practices have 2-3 doctors as opposed to our average of 6-7.

Most have list sizes of 1600 or lower and that I itself makes for a less stressful environment. The working day generally approaches the normal for the working population of the country being 8 hours a day or fewer – in the Danish system GP surgeries close at 4 pm on Monday to Thursday and at 2 pm on Friday. The health of the Danish population does not seem to be adversely affected by this restriction of GP hours of access. However despite this 76% of EU nations feel that general practice workload is unreasonable and unsustainable.

If the nations that think the workload in general practice is reasonable are examined, they tend to have some factors in common. They have a normal working day – that is, eigth hours or fewer and mostly have a list size of 1600 or fewer per GP. They are more likely to have longer consultations and, of course, have easier access into secondary care beds. However, the factor that seems to be the most important is the number of patient consultations per doctor per day.

Consultation length and duration

Most nations have 15 minute consultations with the Scandinavian countries veering towards 20-25 minutes. Those nations with 25 consultations or less a day find general practice manageable. Those nations who either have telephone consultations or face-to-face consultations that exceed 25 patient contacts a day per doctor find general practice unsustainable. They have problems in both retaining GPs and in recruiting newly qualified doctors to a GP training programme.

Home visits

Most do little home visiting – though this may be due to the greater availability of beds in European countries. The UK has the lowest bed numbers per 100,000 population in Europe with France having double the beds and Germany three times as many. This means that admission of sick patients is more or less the norm, rather tha, as in the UK, making huge efforts to keep patients out of hospital.

Summary

A profession under stress is a profession at risk. Maybe the answer is simply to reduce access to EU levels; to restrict doctor-patient contacts, both telephone and face-to-face consultations, to fewer than 25 a day. It may be possible to divert some demands to pharmacists, nurses or other health professionals. It may be possible to educate the public to self-care, at least for minor illnesses.

General practitioners are expensive and time-consuming to train. It would be sensible to use their skills carefully.

"It's passed on!. This NHS is no more! It has ceased to be! It's expired and gone to meet its maker! It's a stiff! Bereft of life it rests in peace! It's kicked the bucket! It's shuffled off this mortal coil and run down the curtain to join the choir eternal! IT IS AN EX NHS!!!"